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Case 2 - Pulmonary Embolism

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This is a companion case of a 42-year-old woman with, again,

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acute shortness of breath, who comes to the ER.

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CT of the chest with IV contrast was performed.

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And in the scout view, again,

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opportunity for us to take a survey of what's going on.

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The lung fields are equally inflated.

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There's no focal consolidation that we can

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appreciate here. No large pleural effusion or pneumothorax.

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The heart's a little prominent.

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The bones themselves look intact.

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They don't see anything that looks destructive or truly out of place.

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We see that there are surgical clips

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in the upper left quadrant, as well as in the upper right quadrant.

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So there may have been some gastric surgery and a cold cystectomy.

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We can make out here portion of the liver shadow, which looks a little enlarged.

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Probably won't see it in its entirety,

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but again, the scout view is a great way

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to take a survey of the overall image area.

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So we'll take a look at the axial images.

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Let's just pull these up to the top.

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And we went through a lot of the systematic approach in the last case.

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So here we'll just really kind of focus on some of the salient issues.

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But again, I like to start on soft tissue windows,

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being able to look at it and assess the vasculature.

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And if we come down, again,

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paying attention, I try to clear the aorta first.

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You can see the coronary arteries are really nicely identified here.

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There's no aneurysmal dilatation,

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nothing that looks like a dissection in the aorta, normal caliber.

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And just taking it all the way down below

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the diaphragm and you see, again, the first takeoff, which is the celiac artery.

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On the way back up, we'll take a look at the pulmonary

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arterial tree, and I usually will start on the left.

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And you can see the a little filling defect

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right here in a subsegmental branch, in the left lower lobe.

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We'll see another one here.

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We come back down on the main left, looks pretty good. But on the right side,

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it's a large thrombus that's sitting right in here.

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And you can see there's some contrast coursing around it.

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So it's not completely occlusive, but it is a pretty large caliber.

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And you can see it extends into some of the smaller branches as well.

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Taking a look at the other portions

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of the right, you know we're not getting good opacification here of the vessels.

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And sometimes that happens.

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And so, it's important for you to,

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in your report, really identify to what level of confidence you're talking.

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So sometimes you can only see centrally.

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Sometimes it may be, you can see the lobar but not the subsegmental.

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And so, it's helpful just to let the reader know what they can expect in terms of your

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level of confidence or where we're talking.

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So here, I think we can certainly say,

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centrally, there's a large filling defect to large thrombus here.

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So we want to make sure that we're looking for some of the other problematic issues.

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So, again, looking at the caliber of the main pulmonary artery,

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it's probably top limits of normal, just looking at it from my perspective.

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But what we do notice, or what I do notice really nicely here,

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is how compressed the left ventricle is compared to the right ventricle

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and that you do have some degree of contrast refluxing into the intrapatic

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IVC, and probably to some extent, some early hepatic veins here.

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And so all of this suggests that there,

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again, is right heart strain, secondary to the central thrombus obstruction,

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causing increased pressures in a low pressure system.

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So we want to make sure that we're looking for issues in the lungs themselves.

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So, is there any evidence of pulmonary infarct?

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And so you see some of this ground glass, hazy opacity here at the apices,

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there is this focal opacity here.

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As we move through the lungs,

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there's definitely some degree of ground glass opacity scattered around the lungs.

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You see them again down here.

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You see some opacities that look more typical for atelectasis.

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So sometimes it can be difficult to discern, you know, what is taking place.

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So this is a patient who does have a significant thrombus load,

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who obviously will be predisposed to having pulmonary infarcts.

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But remember that patients can also have other things going on.

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And so in many ways,

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while not every entity reads the same textbook in terms of being classic, and we

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think about pulmonary infarcts as being wedge-shaped peripheral opacifications or

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consolidations, they may not always look that way.

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And so some of these may be early and forming infarcts, the stuff that's more

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central, could certainly be another process.

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So, you know, I would certainly include in the differential or ask whether or not

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there's any evidence of infection, kind of inflammatory infectious process that's

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maybe atypical, or are we looking at early infarcts that are developing?

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So sometimes it's not always clear,

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but you want to check the boxes on things to consider.

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So certainly with the patient with pulmonary emboli,

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you want to consider, is there heart strain? Is there evidence of reflux

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of contrast, elevation of pressures with an enlarged pulmonary artery?

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Do we have evidence of pulmonary infarct?

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And include that in your description.

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So this is a companion case of a patient who does have left ventricular decreased

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caliber, secondary to elevated pressures on the right.

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You see that kind of moving throughout the system as well as precursors

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in the intrahepatic IVC with a very central thrombus.

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That is an explanation for the patient's shortness of breath.

Report

Faculty

Jamlik-Omari Johnson, MD, FASER

Chair, Department of Radiology

University of Southern California

Tags

Vascular

Trauma

Myocardium

Lungs

Infectious

Idiopathic

Emergency

Chest

CT

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